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BY ELENOR K. SCHOEN, REGISTER CORRESPONDENT
OLYMPIA, Wash. — Scores of Washingtonians “have become a victim” to the state’s one-year-old physician-assisted suicide law, said a pro-life hospice nurse.
“Thousands of others, including senior citizens and people with disabilities, have received the message that they, too, are expendable,” said Eileen Geller, founder of True Compassion Advocates, an organization that campaigned against Initiative 1000 and now provides information for those seeking good end-of-life care.
Today is the first anniversary of the law. Washington legalized the practice through a public referendum, Initiative 1000.
Dominican Sister Sharon Park, executive director of the Washington State Catholic Conference, agrees that the law places “vulnerable people at risk of abuse.” The legislation, she said, “was written to prevent adequate safeguards for persons most in need of care and support.”
Geller said that while Washingtonians “thought that they were voting for a voluntary ‘choice,’” they got instead “a law that encourages patient coercion and allows involuntary killing.” It is, she believes, a “recipe for elder abuse and abuse of people with disabilities.”
In July 2009, Margaret Dore, a Seattle attorney with expertise in probate, guardianship and elder law, wrote an article for the Washington Bar Association, in which she describes the abuse potential in the Death With Dignity Act.
Dore wrote that the Death With Dignity Act “contains potentially coercive provisions [that allow] an heir, who will benefit from the patient’s death, to help the patient sign up for the lethal dose. She stated that: “Having an heir act as one of the witnesses creates a presumption of undue influence [that] does not promote patient choice [but] invites coercion.”
She addressed the issue of “self-administering” the drug, stating that the law “does not state that ‘only’ the patient may administer the lethal dose [but] is instead defined as the act of ingesting. In other words, someone else putting the lethal dose in the patient’s mouth qualifies as ‘self-administration,’ [or] putting the lethal dose in a feeding tube or IV nutrition bag.”
The attorney discussed the issue of competency, noting that: “The act does not require that the patient be competent or even aware when the lethal dose is administered… [nor is there] language requiring the client’s consent at the time of administration. Without a requirement of competency, consent, or even awareness when the lethal dose is administered, the stage is set for undue influence and worse,” she concludes.
The Washington State Department of Health reported this week that lethal doses of medication were dispensed to 63 people between March 5, 2009, and Dec. 31, 2009.
“Of the 63 individuals who received lethal doses of prescription medication last year, 47 are known to have died,” the department said in a March 4 press release. “Thirty-six died after ingesting the medication…. Most had terminal cancer and all were expected to die within six months.”
The department said that according to prescribing physicians, all the patients who received the lethal medications and died had expressed concern about loss of autonomy as a reason for requesting a prescription.
Under the Death With Dignity Act, the physician cannot list assisted suicide as the cause of death but instead must report an underlying illness present at the time of death. If the death certificate isn’t sent to the health department, there is no way of knowing if the deceased died from assisted suicide or not.
Death With Dignity ‘Choice’
Amber Wade, a staff member of Compassion & Choices, the pro-assisted suicide organization which sponsored the initiative to push legalization, discussed the services her organization provides. She explained that Compassion & Choices will “discuss all of a patient’s end-of-life options with them and encourage patients to get into hospice” as 95% of their clients die while in hospice care. Wade said that hospice care “ensures more support, pain-symptom management and after-death support for the family.”
Compassion & Choices staff “help to facilitate conversations about death and dying with the patient and their family, help with advance planning for healthcare documents, providing emotional support, information and referrals,” she stated.
“Less than half of the patients that we work with are pursuing Death With Dignity,” Wade emphasized, adding: “We are not a pro-Death With Dignity organization, but a pro-choice organization that supports a patient’s right to control over their own care [requiring education about what their choices are],” she continued.
“Even with pain and symptoms properly managed, there are still terminally ill patients that want to have Death With Dignity as an option. And we support that choice,” Wade said.
Good End-of-Life Care
The state’s bishops conference’s Sister Sharon Park said the Church “continues not only to provide a pastoral response for terminally ill persons, but also to advocate for a change in the law.”
All three of the statewide Catholic health care corporations have chosen to “opt out” of the Death With Dignity Act, permitted under the law. This means their clinicians are prohibited from participating in the formal process outlined in the law — that is, the initial consult, second opinion, psychiatric evaluation if the patient is found to be depressed, and in the dispensing of the lethal prescription. Some of the non-Catholic hospitals, hospices and nursing homes have “opted in” in allowing assisted suicide in their facilities.
“Opting out” facilities, according to the Death With Dignity Act, “have an obligation to openly discuss the patient’s concerns, unmet needs, feelings and desires about the dying process. Providers should seek to learn the meaning behind the patient’s questions and help the patient understand the range of available options, including but not limited to comfort care, hospice care and pain control.”
Ross Fewing, spiritual care director at Bellingham’s St. Joseph Hospital, however, has seen a positive reaction to the difference Catholic health care provides.
“What has been an unexpected benefit of the discussion with the community concerning our stance against the Death With Dignity Act has been a productive discussion on providing quality end-of-life care that includes both hospice and palliative care,” Fewing acknowledged.
St. Joseph Hospital, under the auspices of PeaceHealth, “has system policies regarding physician assisted suicide [that] were developed in our 10-plus years’ experience in Oregon under a similar law,” according to Bridget Carney, a nurse who is system director of ethics and theology for the corporation.
Their clinicians are prohibited from participating in the process outlined by the Death With Dignity Act. But they are not prevented from discussing with their patients “their concerns about options for treatment and care,” Carney explained.
They provide no referrals to physicians who provide assisted suicide or to organizations that promote the Death With Dignity Act. What they do offer are “quality hospice services.”
In the case of depression, Carney explained that a patient “can have a primary physician or oncologist, working at an ‘opt out’ facility, who can provide care and assess the need for referral for psychiatric evaluation for depression for a patient anytime.”
But she went on to explain: “If this same patient decides they want to pursue obtaining the lethal prescription, the patient would need to find a physician who is willing to provide the prescription for the patient (provided the patient qualifies under the law).”
“This ‘attending physician,’ who is not working for the ‘opt out’ facility, would then assess the patient’s request and evaluate whether there is a need for further assessment regarding depression,” Carney stated. If a patient needs a psychiatric consult, this outside physician would fill out the paperwork for a consult, which is part of the process for obtaining the lethal prescription.
A provider from the “opt out” facility can treat a patient, but is “prohibited in participating in any of the steps of the process for obtaining the lethal prescription.”
“The patient is never abandoned, or left without access to care, by an opting-out facility provider. They can provide quality, compassionate palliative and hospice care to the patient and families,” Carney said.
If a hospice patient chooses to end his or her life by taking a lethal overdose, “our staff cannot be present with the patient or family when this happens,” Carney stated.
However, “the family can call us afterwards. Our staff will provide supportive care,” doing nothing to hasten the death of the patient, she emphasized.
The two other statewide health-care organizations, Franciscan Health System and Providence Health and Services, have similar positions on the Death With Dignity Act.
Franciscan’s website states that “Franciscan Health System does not participate in, nor facilitate, physician-assisted suicide,” a philosophy “rooted in our faith tradition and belief that all life is sacred, from conception to death … guided by the [U.S. Conference of Catholic Bishops’] ‘Ethical and Religious Directives for Catholic Health Care Services,’ which does not condone physician-assisted suicide.”
In caring for their patients, they will “never strive to hasten death nor would we abandon the dying person … [but will focus on] providing compassionate care for terminally ill individuals through our inpatient and in-home hospice service and other programs benefiting those nearing the end of their lives, [including] spiritual care and bereavement support for our patients’ loved ones,” said Gale Robinette, a spokesman at Franciscan Health System. Robinette said that, so far, there have been no requests for assisted suicide that he is aware of, a situation shared by PeaceHealth. And like PeaceHealth, if such a request arose, its hospice caregivers would continue to care for the patient, leaving the premises before a lethal overdose was taken.
Rob Luck, manager of specialty programs for Providence Hospice of Seattle, said that Providence Health and Services “has made it very clear to current or prospective patients and their families that Providence Hospice of Seattle, as a Catholic health-care organization, will not participate in physician-assisted suicide … in keeping with the Providence Health & Services policy and with the National Hospice and Palliative Care Organization’s policy.”
He stated that “while we will not actually participate in or facilitate any aspect of the act, we will continue to provide [our hospice patients] with excellent hospice and palliative care if they choose to use these services.”
Suffering Brought on by Patient ‘Choice’
But unlike PeaceHealth and Franciscan, Providence Hospice has received four requests by patients in their care for assisted suicide.
According to Rob Luck, the issue “is a very real one for our staff. …The greatest challenge has been the difficult emotional effects that result from working with patients who choose assisted suicide.”
Luck explained: “By nature, hospice workers are deeply compassionate and committed clinicians who take their work very personally, making it difficult to accept the fact that, despite our best efforts, some patients choose physician-assisted suicide over the natural death that comes as a result of their illnesses.”
In order to deal with the anguish this has caused these caregivers, Providence has “instituted a policy to provide support for clinicians that begins shortly after we are aware of a patient’s decision to pursue physician-assisted suicide, and continues after the death of that patient.”
Luck believes that “this issue will continue to be one that is both emotionally and spiritually challenging for our staff.”
In a related story, a hospice nurse affiliated with a nonreligious nursing home in Washington that has opted to allow assisted suicide, reported that staff “were standing in the hall outside the room of a patient who had just taken a lethal overdose, weeping inconsolably, until a chaplain and counselors were called to comfort them.”
Marie Hilliard, director of bioethics and public policy for the National Catholic Bioethics Center in Philadelphia, addressed the ethical implications arising for staff and for care facilities when patients request assisted suicide.
In cases where a hospice is opting out of involvement in assisted suicide, Hilliard stated: “Home hospices should have a policy of transfer of care of any patient who requests assisted suicide.”
The Death With Dignity Act actually allows this transfer if the opting-out health-care facility wishes to do so.
This transferring of care is not done in order to accommodate a patient to receive assisted suicide somewhere else, she said, but because “the provider and the client disagree on the care to be rendered, or [because the care requested] is not available.” Hilliard suggests that in cases where “some hospices choose to retain care in the hope that they can impact a better end-of-life care approach … that could be morally licit.” This comes under the definition of “mediate material cooperation [where] there is a good to be achieved or an evil to be averted,” she said.
A hospice program that is not participating in assisted suicide may hope that “through its willingness to try to address depression and pain, it can avert the use of such lethal medication for assisted suicide, a good could be achieved, and the providing of such care could be morally justified,” Hilliard explained.
But in order to prevent any confusion about its motives by allowing care up to the point of the patient taking a lethal overdose, “good public education as to policy of the hospice needs to be provided.”
Elenor Schoen writes from Shoreline, Washington.